Emergency Information/medical Release Form printable pdf download

EMERGENCY INFORMATION/

MEDICAL RELEASE FORM

First Name: ________________________________ Last Name: __________________________________

Address: ______________________________________________________________________________

City:_________________________________________State:_________________Zip:________________

Parent/Legal Guardian: ____________________ Emergency Contact Phone Number: (_____)__________

Date of Birth: ________/______/___________ Age: ________ American Citizen (Yes/No): ____________

In order to compete in rugby, all players MUST undergo a physical evaluation and seek health/medical

insurance coverage with a requirement of $1000, 000.00 as required by the WAIVER of LIABILITY and

ELIGIBILITY FORM. Rugby is a contact sport and RISKS OF SERIOUS INJURY DO EXIST including

permanent disability, paralysis and death; these risks and dangers may be caused by a participant’s actions or

inaction’s, action or inaction’s of others in the Activity, or the condition in which the Activity takes place.

Emergency information provided by the participant and his/her parent or legal guardian is essential in case of

an accident or injury. The signature below confirms that all information provided is complete and accurate.

Parent/Legal Guardian Signature: ________________________________________ Date_____/____/____

Athlete Signature: ___________________________________________________ Date ____/_____/_____

MEDICAL EMERGENCY AND INSURANCE INFORMATION

Name of Physician: ____________________________Physician Phone Number: (____)_______________

Name/Relation of Emergency Contact: _________________Contact Phone Number: (_____)___________

Insurance Provider: ______________________________Group Number: __________________________

Policy Number: ____________________ Known Allergic Reactions: ______________________________

Additional Major Medical Concerns: ________________________________________________________

PARENTAL CONSENT AND IDEMNIFICATION AGREEMENT

I, the minor’s parent and/or legal guardian authorize and consent to medical, surgical and hospital care,

treatment and procedures to be performed by available medical staff and/or a licensed physician when

deemed necessary or advisable by appointed representatives in case of my absence. I waive my right of

informed consent to such treatment and release from any litigation expenses, attorney fees, loss liability, and

damage or cost Releasees may incur as the result of any such claim.

Parent/Legal Guardian Signature: _______________________________________ Date: ____/_____/____

Emergency Information/medical Release Form